DESCRIPTION (AS PROVIDED BY APPLICANT): The overall aim of this study is to develop clinical decision support system design tools to decrease the incidence of medication administration errors. While clinical decision support systems can potentially decrease a variety of medical errors, they are often difficult to integrate into the clinical workflow. In part this is because end users asked for input into systems design cannot always articulate how the tools will work in the actual environment. To improve the decision support design process, we will develop a simulated system that includes the relevant and realistic elements of the actual clinical environment and will use teams of nurses to test its applicability to real-world settings. Nurses are at the sharp end of the medication administration process and it is these errors that can result in the direst consequences. They are also errors that CPOE alone is unlikely to reduce and it is these medication administration errors that we are targeting in this project. The outcomes of this project will include an exportable, contextually sensitive systems analysis tool to aid in the design of decision support for nursing medication administration. The specific aims of this study are to: 1. Modify a simulated clinical information system to include a suite of decision support tools for medication administration within intensive care. 2. Engage teams of intensive care unit nurses to identify how these tools can be customized for optimal decision support within their clinical environment 3. Design supporting materials to accompany the resulting decision support tools and simulated information system for their use as a contextually sensitive system analysis tool for general use. Relevance: It is estimated that adverse drug events (ADEs), resulting in injury or death, affect more than 770,000 people annually. Many of these errors occur during the administration of medications and can be prevented if nurses are provided with medication administration decision support at the right time and in the right format. This study will provide hospitals with the tools to conduct simulations for the design of computerized decision support for nurses during medication administration. [unreadable] [unreadable] [unreadable] [unreadable]